1. Gastrostomy Tube Reinsertion
Ramona Garcia

2. Medically Fragile Our students
New Jersey defines the medically fragile as one who suffers from a life threatening medical condition… and need individualized and continuous care typically provided by a school nurse …
Our students

3. Background
1970: student needs were meet by hospitals and other institutions
Educational Development
Medical Requirements

4. This changed the scope of education for the medically fragile
Background
1975: The Education for LL Handicapped Children Act (EAHCA) public law
Disabilities Education Act (IDEA)
This changed the scope of education for the medically fragile

5. Background
EAHCA and IDEA identified the need to provide services to a large population of school age individuals who were not serviced or were under serviced
Entitles all students to an education especially those who require complex health procedures

6. School Nursing Today More Students More Regulations on care
State, District, Board of Nursing laws, policies and guidelines

7. Students with Handicaps of Chronic Illnesses
Autism
Deaf-blindness
Emotional Disturbance
Hearing Impairment
Mental Retardation
Multiple Disabilities
Orthopedic Impairment
Visual Impairment including blindness.
Specific Learning Disability
Speech or Language Impairment
Traumatic Brain Injury
Other Health Impairment

8. How will we meet the needs for the student with a gastrostomy tube ?

9. Nursing Practice Law 15.24 Eight Steps to Success
Provides specific guidelines, rules, and considerations that must be applied in order for the reinsertion of the gastrostomy tube
Eight Steps to Success

10. Nursing Practice Law 15.24
The length of time the student has had the tube in (8-12 weeks at least) for maturation/healing of the fistulous track and stoma formation
Orders must be obtained by a physician

11. Nursing Practice Law 15.24
The nurse should complete training designed specifically for the type of permanent feeding tube, including overall patient assessment, verification of the proper tube placement, and assessment of the tube insertion site
The nurse demonstrates competency in all appropriate aspects (knowledge, decision making, and psycho-motor skills of performing the procedure

12. Nursing Practice Law 15.24
The patient has an established tract as determined by a physician
The facility has resources available to develop an education program for initial instruction of RNs and LVNs as well as ongoing competency validation

13. Nursing Practice Law 15.24
Documentation of each nurse’s initial education and ongoing competency
Regardless of training, policies, and procedures, the facility must also permit the nurse to engage in the procedure

14. MIC-Key Button Gastrostomy Tube
balloon inflation valve
anti-reflux valve
The end of the balloon has a tapered tip and a inflatable balloon that is filled with water after the catheter is in place and keeps the catheter in place

15. What if the tube becomes dislodges?
Remember the feeding tube tract can narrow and close within hours of the tube removable

16. Equipment Needed to Replace a Feeding Tube
Gloves
Stethoscope
Gastrostomy tube
Lubricant
Syringe that fits tube for air insufflations
Syringe the fits tube for saline inflation
Saline

17. Replacing a Feeding Tube
Assess site and balloon
Is there a leak?
Yes reinsert tube and notify physician
Are there signs of infection?
Yes  reinsertion is contraindicated

18. Replacing a Feeding Tube
Lubricate tubing
Gently insert into the tract
Never force tubing: this can cause a separation of the stomach lining
Check placement by inserting 20-30cc of air and auscultation of stomach
You may also see gastric contents in the tubing.

19. Replacing a Feeding Tube
Insert 100cc on saline using a 100cc syringe into the anti-reflux valve
Proper documentation of the procedure
Notify parent or guardian before the next feed

20. Complications to monitor and address
Blocked or clogged tube
Any signs of infection
Redness
Swelling
Warmth
Discharge: yellow, green, or foul-smelling
Severe abdominal pain
Excessive bleeding or drainage from the tube site
Persistent vomiting or diarrhea
Trouble passing gas or having a bowel movement
Pink-red tissue (called granulation tissue) coming out from around the g-tube

21. IT’S NOT OVER TILL THE PAPER WORK IS DONE!

22. Practice Makes Perfect

23. ??? Questions ???

24. References
David Matthau, "Protecting Jersey's Medically Fragile Kids At School."
Ruby Ferguson MSN, RN, "Gastrostomy Tube Feeding int the School Setting."
Texas State Board of Nursing Rules and Policies: Regulation number 15:24
Dr. Edrik D. Schragg and DrRick Kulkarii, Chief editor Medscape, "Gastrostomy Tube Replacement ( )
American Academy of Chld and Adolescent Psychiatry, "Services In School For Children With Special Needs: What Parents Need to Know" ( )